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DiNapoli: Office of Children and Family Services Can Improve Efforts to Investigate Child Fatalities

January 24, 2023

An audit released today by New York State Comptroller Thomas P. DiNapoli found the state’s Office of Children and Family Services (OCFS), which oversees the locally administered child welfare system that investigates reports of alleged child abuse or child fatalities, can take additional steps to protect children from harm.

“The findings in this audit should be a sobering call to action to ensure New York’s vulnerable children are protected,” DiNapoli said. “New York’s Office of Children and Family Services (OCFS) consistently finds flaws in child abuse investigations that preceded a child’s death. It can do more to ensure that local social service providers throughout New York improve operations so they can better respond to abuse complaints and save children’s lives.”

DiNapoli’s audit found OCFS can significantly improve how it reviews incidents of children dying from abuse. When the review of a child fatality investigation finds statutory or regulatory compliance failures and deficiencies in practice, the local departments of social services (LDSS) must develop and submit a Program Improvement Plan (PIP) to OCFS for approval.

Auditors found that while OCFS generally identifies deficiencies in child fatality investigations and in prior investigations relating to that child, the PIP only applies on a case-by-case basis and fails to make recommendations to fix systemic problems that might be occurring statewide. Although the identification of deficiencies after the fact may provide useful information and areas for improvement, ultimately the worst outcome has already occurred. It is critical that any deficiencies are addressed proactively to help guard against child fatalities.

From 2018 to 2021, OCFS received approximately 1,400 reports involving allegations of fatal abuse or maltreatment of children. OCFS issued 2,752 citations to LDSSs, indicating a problem with the local investigation. Citations were given to nearly half (641) of all investigations into a child fatality. The greatest number of citations were issued to cases in The Bronx (317), Manhattan (248), Brooklyn (240), Onondaga County (228) and Erie County (137).

Nearly three-quarters (72%) of the problems OCFS found were related — not to the investigation of the fatality but to previous investigations involving mistreatment of the child — suggesting that investigative weaknesses existed prior to the child’s death.

Auditors examined 52 child fatality reviews to understand how OCFS addressed the problems it found. OCFS identified defects in all 52 cases and in 51 of them the LDSS created a PIP. However, there was little consistency in how PIPs addressed deficiencies, and OCFS could not easily monitor deficiencies or corrective action among LDSSs or even within regional areas.

Auditors also found other issues with OCFS’ oversight, such as lack of a statewide plan to address issues found across LDSSs and that several investigations not yet reviewed by OCFS also lacked evidence to support that required steps had been completed.

DiNapoli’s audit recommended OCFS establish procedures to more accurately reflect the nature of calls determined to be non-reports and reasons for such determinations, address deficiencies found in Program Quality Improvements and child fatality reviews across all LDSSs statewide and work with LDSS staff to improve investigation documentation.

In its response, OCFS officials generally agreed with the findings of the audit and expressed appreciation for OSC’s acknowledgment of steps that the agency has taken to improve oversight and monitoring.

Audit
Office of Children and Family Services: Oversight of Child Protective Services


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